COVID-19 Patient Disclosure – True North Community Dental Clinic

"*" indicates required fields

First Name*

Last Name*

Email*

Do you have any COVID related symptoms? (Including fever, shortness of breath, dry cough, loss of sense of taste or smell)*

Yes

Have you been in close contact with someone who has tested positive for COVID?*

Yes

Are you or someone in your household awaiting a COVID test result?*

Yes

Date*